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Anahtar Kelimeler

Myomektomi, Gebelik

Giriş

The prevalence of uterine myomas in pregnancy ranges from 0,1% to 5% (1-3). The uterine leiomyoma may be responsible for number of complications in pregnancy depending on the size, number, location, and relationship with placenta (2). A marked increase in pelvic pain, abortion, preterm delivery, abruptio placenta, malpresentation, and cesarean delivery rate is reported in these pregnancies (3). Less common or rare complications include growth restriction, sepsis, L-5 radiculopathy, disseminated intravascular coagulation, urinary retention, and fetal anomalies (4). Even though there are apprehensions for abortion and preterm delivery for myomectomy itself during pregnancy, in such cases mentioned above the procedure may be inevitable. Because of their relative infrequency, the question arises often as to whether the diagnosis of leiomyoma can be confirmed during pregnancy. The clinical question is what impact the leiomyoma will have on the pregnancy and whether a myomectomy can be performed safely at some stage of the pregnancy.

Olgular

Olgu 1

A 35 years old, gravida 9, parity 4 woman was hospitalized for pelvic pain at 19 weeks' gestation. On admission, ultrasonographic examination showed a solid mass of 12 centimeters in diameter adjacent to the gravid uterus. Magnetic resonance imaging (MRI) revealed the mass to be of uterine origin (Figure-1 and 2). Relief was achieved by non-steroidal anti-inflammatory agents. The ethic committee decided on expectant management and so the patient was followed in an outpatient regiment. On the follow up, progressive abdominal pains unresponsive to medical treatment were encountered, and, so on the 21st. week of the pregnancy laparotomy was performed. On surgical exploration, a fundal pedunculated, degenerating myoma of nearly 15-centimeter in diameter with a stalk of 3-cm diameter was found. Consequently myomectomy was performed. The operation took 17 minutes overall. Pathological examination of the mass confirmed the diagnosis of degenerating leiomyoma. Pregnancy was progressed to the term without complications and a 3400-gram male baby was delivered by elective cesarean section. Neither neonatal nor puerperal complication occurred.

Olgu 2

A calcified solid mass of 10 centimeters in diameter was observed during routine ultrasonographic examination of a 32 years-old primigravida woman with 12 weeks' gestation. In further evaluation of this asymptomatic mass, MRI showed a large myoma situated in the anterior aspect of the gravid uterus. In two weeks, the patient started having recurrent attacks of pelvic pain consistent with torsion of the uterine leiomyoma. Failure of medical treatment with non-steroidal anti-inflammatory agents led to the decision of laparotomy at 19 weeks' gestation. Explorative laparotomy revealed an uterine myoma of 12 centimeters in diameter with a short, thick pedicle. Successful myomectomy was performed in a period of 20 minutes. Pathological evaluation confirmed the diagnosis of leiomyoma. No complications were encountered during the rest of the pregnancy. A healthy boy of 4000 grams was delivered by elective cesarean section.

Tartışma

The overall risk of major complications in pregnancies with uterine leiomyoma is reported as 71% (2-5). Pelvic pain is the most frequent one among these (2,3). The cause of painful myomas is thought to be red degeneration and less likely the torsion of the pedunculated one. The diagnosis in these cases usually obtained by using ultrasound or MRI. MRI is increasingly applied for the quantitative evaluation of uterine leiomyomas. In contrast with ultrasound, MRI offers greater tissue contrast and better tissue characterization (6). MRI can provide precise presurgical mapping prior to myomectomy. Riccio et al. reported that MRI added additional diagnostic information in 78% of cases (7). Generally myoma in pregnancy is approached with expectant management. When the pelvic pain occur, treatment with bed rest, hydration, nonsteroid anti-inflammatory agents, and vitamin E is claimed to be effective (8,9). However, medical treatment sometimes fails and myomectomy would be inevitable (10, 11). Myomectomy as a treatment for the syndrome of painful myomas in pregnancy has been explored in the literature (8, 10, 11). Burton et al confined their recommendations for myomectomy in pregnancy to symptomatic myomas that are pedunculated with a stalk of 5-cm diameter or less (12). Exacoustos and Rosati recommend consideration of both clinical symptoms and myoma characteristics on ultrasound in decision-making (2). Mollica et al suggested additional criteria in asymptomatic patients for elective myomectomy that consisting large or rapidly growing myomas, large or medium myomas located in the lower uterine segment or deforming placenta. According to these criteria they operated 18 patients and reported good fetoneonatal outcome with no abortions, while in group of 88 pregnancies followed by conservative regimen, 13,6% abortion rate was observed (13).

Sonuç

As a conclusion we think that myomectomy in pregnancy might be performed safely in selected cases. Parallel to the published data we also conclude that the risk of complications due to myomectomy is not significantly increased.